We have an incredibly special episode for you today with the one and only Lily Nichols! She is a registered dietitian nutritionist and the author of two books (soon to be three!)-- Real Food for Pregnancy and Real Food for Gestational Diabetes. Lily is truly a pregnancy nutrition expert providing women with access to the most current evidence-based information regarding food. 

Lily specializes in helping women with gestational diabetes feel empowered with options to help their blood sugar stay diet-controlled. This important work is helping women with gestational diabetes have healthier pregnancies and more birthing options when so much of the conversation around it becomes limiting and fear-based. 

Whether you have gestational diabetes in your pregnancy, are pregnant, preparing to be pregnant, or just want more nutrition education, this episode is for you!!

Additional Links

Lily’s Website

Real Food for Gestational Diabetes

Real Food for Pregnancy

How to VBAC: The Ultimate Prep Course for Parents

Full Transcript under Episode Details 

Timestamp Topics

09:28 What is gestational diabetes? 

11:15 Are there preexisting signs and ways to prevent it?

13:59 What can we do? 

17:00 How much protein you should get in pregnancy

19:11 Best sources of protein

22:04 Getting enough protein on a meatless diet

26:17 Fats & Gestational Diabetes

31:14 Do we have to have a baby at 38 weeks with gestational diabetes?

32:28 The problem with the standard gestational diabetes guidelines

40:20 PCOS and gestational diabetes

Meagan: Hello, hello everybody. This is The VBAC Link and we have a very special episode for you today. This is a topic that if I were to show you in the inbox, you would be like, “Whoa. I didn’t realize so many people have this question.” The question is– I mean, there are lots of questions– but the topic is gestational diabetes. 

So if you have any questions about gestational diabetes, this is your episode for sure. And then actually, right before we started recording, I learned there are even other things that make us at high risk or are a known risk for gestational diabetes. Even if you haven’t ever had gestational diabetes, you’re going to want to listen because there are things that we can do preventatively before pregnancy or during pregnancy to avoid it. 

But you guys, we have the one and only Lily Nichols on today with us talking about this extraordinarily common topic. Lily Nichols is a registered dietitian nutritionist and certified in diabetes education. She is a researcher and an author with a passion for evidence-based prenatal nutrition. Drawing from the current scientific literature with the wisdom of traditional cultures,  her work is known for being research-focused, thorough, and sensible. Her best-selling book is Real Food for Gestational Diabetes. 

I absolutely love that the start of this is “Real Food”. Real food is something that I don’t feel like we focus on enough in our every day– not even during pregnancy– lives. We live busy lives, so it’s hard to focus on real food. But Real Food for Gestational Diabetes and you guys, she has an online course with the same name so Real Food for Gestational Diabetes Online Course. 

She is absolutely amazing and has even written two books and now what I learned today is going on the third, so Real Food for Pregnancy and Lily, what is the title of your new book?

Lily: The forthcoming book is Real Food for Fertility. 

Meagan: For fertility. Oh my gosh, you guys. She is evidence-based. It’s amazing and you know here how much we respect evidence-based information and getting this to you guys so you can know the true facts and go on and make decisions that are best for you. 

So Lily, thank you so much for being here with us today and talking about this topic because like I said, it is one of the most common questions we get in our inbox. 

Lily: Yeah, absolutely. I’ve spent a lot of work working on gestational diabetes so I’m happy to speak about it with you today. 

Meagan: Yes. Can you tell us a little bit more about your course? I’m going to start there because you have an online course. I think this is a great thing for anyone who has either had gestational diabetes or has it to really learn more about it. 

Lily: Yeah, absolutely. The course is really designed for women with gestational diabetes not necessarily healthcare professionals and it kind of expands upon the information that is in the Real Food for Gestational Diabetes book so additional, practical resources that support the same principles that you learned in the course but takes it to another level so there are additional meal plans. There are three weeks worth of meal plans and several different carbohydrate levels so you can customize them. 

There is more information on lowering your fasting blood sugar naturally with the hopes that we can reduce or minimize your risk for medication or insulin which, depending on where you are and who your provider is can limit your birthing options. Also, I generally disagree with it, that is often a policy. We really often try to use food and lifestyle as much as possible to enhance our ability to keep our blood sugar under control. 

Probably some of the biggest benefits, though, of the course is that we do have a private Facebook community just for course participants and I do host weekly office hours. People will share what’s going on with their blood sugar. “Hey, I’m struggling with this with my fasting blood sugar. I’ve tried x, y, and z and it still hasn’t worked. Do you have any tips for me?” We have a really active community in there. 

Once you are a member, you are always a member. We have some moms who are on their third pregnancies and still in the course that can offer feedback but I also answer questions every single week. I’ve been told that arguably the biggest benefit is you can get my eyes on it and get a second opinion. Since I don’t have a whole lot of availability for one-on-one clients, it’s really the main way you can get my feedback on what’s going on. 

That’s helpful, I think because there really isn’t a one-size-fits-all intervention for gestational diabetes. Obviously, there are some general truths that work food and lifestyle-wise, but individual tinkering is something where you really need individualized attention versus, “Here is this snack that works for every single woman.” There really is no such thing. I wish there was. It would make my life way easier. It would make everybody’s lives easier. It would make the diagnosis less frustrating. 

But oftentimes, it’s like, “Okay. I need to get my blood sugar under control in two weeks otherwise they’re going to put me on medication.” People really need that kind of information right away at a really important time point in their pregnancy. 

Meagan: I love that you say that. We have private groups too and I feel like these groups are just money. 

Lily: Oh yeah. 

Meagan: Even just seeing things that other people are asking and you’re like, “Oh, actually I have that same question,” then maybe you reply to them and it just filters down. Those groups are so awesome. I love that you have created that and created a space for people because I don’t feel like in the medical world– and this is not to shame the medical world– they just don’t have time to do exactly what you were saying. “Okay, you’ve got this diagnosis. Let’s break it down for you as an individual.” It’s, “Here’s a sheet of paper,” that you can pull off of Google. 

It doesn’t mean that it applies to you. You have the diagnosis so it could help you but it doesn’t mean that it’s going to be the best thing for you as an individual. 

Lily: And moreso than that, sometimes you don’t have a provider that is well-informed on the updated research so I get a lot of women in the course who are like, “Okay, I don’t know if I really need this course, but I figured it would be a good idea,” then they jump in and they are like, “I have my meeting with the dietitian this week,” then they come back in the group and they are like, “What the dietitian said that what I’m doing is wrong and that I need to eat this way, so I’m going to try it,” then they come back three days later and they are like, “My blood sugar was terrible. This advice didn’t work. I feel awful. I need to go back to the original.” 

It’s just the ongoing thread of community members who have been through the same thing. Ultimately, that’s why I do the work that I do and write the books that I do because the standard of care just doesn’t often work or it’s 20 years outdated. 

Meagan: Oh, I can so relate to that one when it comes to VBAC. It’s the same thing when we’ve got one provider saying this and then another provider is saying this. It’s a very similar situation. You’re like, “Well, what is it? What does the evidence really say?” 

9:28 What is Gestational Diabetes? 

Lily: Right. 

Meagan: Oh, well okay, so I think I would like to just even start off with what is gestational diabetes. What does that mean? If you get this diagnosis, what does that mean? 

Lily: Yeah. So at its simplest definition, it is blood sugar that is elevated during pregnancy beyond a certain threshold. The whole diabetes during pregnancy, I think, confuses people a little bit because it is like, “How can I develop diabetes during pregnancy but only during pregnancy?” Really, it’s that your blood sugar is elevated beyond a certain threshold. 

There are other definitions like insulin resistance during pregnancy or carbohydrate intolerance during pregnancy. They are all speaking to the same thing. Your body has a more limited ability to bring your blood sugar down within the normal range for whatever reason. 

There can be a number of different reasons. Sometimes there are pre-existing issues before pregnancy that we didn’t know about and during pregnancy, we test for things so there are a whole lot of the population that is walking around essentially with pre-diabetes and has no idea. Then during pregnancy, we screen blood sugar levels to rule out gestational diabetes and then it gets caught on that test. You think that it’s something that developed during pregnancy, but it may have been an underlying blood sugar issue that you had for a while. We are simply identifying it at this point. It can be newly developed or it can be pre-existing and we have identified it at this time point. 

They are technically both called gestational diabetes regardless of the underlying reason. 

11:15 Are There Preexisting Signs and Ways to Prevent it? 

Meagan: Okay. I did not know that. I didn’t know that we could be– it doesn’t just appear. Sometimes it could be preexisting. Are there preexisting signs where we could know that we did have that or are there things that we could do pre-pregnancy to try? Say I have high sugar or whatever right now, but I didn’t know and I get pregnant and I get gestational diabetes, but are there things we can do during pre-pregnancy to– I don’t know the exact way to say it– almost nix it? To try and help reduce it or not have it at all? 

Lily: There are. There’s kind of a mix when we talk about risk factors because some of the risk factors are things within our control and some of the risk factors are things that aren’t within our control. We can’t control whether our mom had gestational diabetes during her pregnancy or whether we have a lot of Type 2 diabetes or insulin resistance in our family. We can’t control our age. We can’t necessarily immediately change our weight at the time of conception. Over the long term, we can have some influence over our weight, but if we are talking retroactively, we can’t go back four months and be like, “Oh, I wish I weighed 20 pounds less before I conceived.” 

You can control, of course, the food you are eating. You can control the micronutrients that you are taking in. There are a lot of nutrients that can reduce our baseline levels of insulin resistance like magnesium and vitamin D and inositol and several other things. Eating sufficient amounts of protein seems to be protective. Our sleep habits can impact our insulin resistance and our stress levels can play a role. 

Gosh, there was one more. 

Meagan: Does high cortisol impact our sugars and their ability to come down? 

Lily: Mhmm. High cortisol raises your blood sugar. Physical activity levels both before conception and during pregnancy– the more exercise we get generally speaking, the lower our risk of gestational diabetes. There are things and sometimes we have so many risk factors that are outside of our control like family history stuff and age at conception where perhaps we have a preexisting elevated risk which makes all of those lifestyle factors that are in your control arguably that much more important because those are the areas where we can make a difference. 

13:59 What Can We Do? 

Meagan: Make a difference. So what can we do? We can lower our stress. We can increase our sleep. We can be physically active. We can eat real food, but can we talk more about that real food? What can we really eat during that? 

Lily: Yeah. The biggest thing to keep in mind, I would say, is your macronutrient balance like your balance of carbohydrates, fat, and protein as well as the quality of the food that you are eating. Specifically looking at eating a sufficient amount of protein, protein tends to be the most stabilizing for our blood sugar levels whereas carbohydrates are the macronutrient that raises our blood sugar levels the most. 

When we eat enough protein, it also has a regulating effect on our appetites since it stabilizes our blood sugar. We don’t get a huge spike and crash like we do with carbs. We don’t get the cravings and that same intensity of hunger leading up to meal time or snack time. So hitting our protein goals is absolutely essential. 

Then second to that, the next most important thing is thinking about the quality of the carbohydrates you consume. It’s kind of wild but in the US, 60% of calories consumed in the average American diet are from ultra-processed foods. These are things made where the primary ingredient usually is a refined carbohydrate of some kind. It’s refined starch or white flour, corn starch, something like that, maltodextrin, or refined sugar like white sugar, corn syrup, high fructose corn syrup, and then all of the random additives and junk added to it. 

Basically, a lot of things that are in the snack and dessert aisle and prepackaged food aisles in our grocery store, breakfast cereals, and that sort of thing. If we simply displace even a portion, even 25% of this majority of our diet that’s coming from ultra-processed foods, we will have better blood sugar levels. Even if they are being replaced by carbohydrate foods but they are not highly, highly processed, you’ll have better blood sugar levels especially if we are replacing some of that with protein-rich foods. 

So I’d say it’s two-fold. It’s like the macronutrients and then it’s the quality of the food reading, trying to eat as many whole foods as possible to displace the processed food items. When you hit your protein food goals, you’re not going to have intense cravings for as much of the processed stuff. 

I like to hit it from the front end instead of being reactive like, “Cut out the processed foods.” That’s easier said than done. What are you going to eat instead? Try getting enough protein and you’ll find that you are drawn less to those foods in the first place. 

17:00 How Much Protein You Should Get in Pregnancy

Meagan: And with protein, do you know on average– I mean, it’s hard because we are all different ages and weights and heights and all of the things. But on average, during pregnancy, how much protein should a pregnant person consume? 

Lily: Yeah, there are ballpark metrics that we can use and there are some that are more specifically based on an amount of protein based on how much you weigh because protein needs are individualized by a person’s body size. If we just use a standard 150-pound woman, in early pregnancy, you need about 80 grams of protein and then in late pregnancy, you need a minimum of about 100 grams per day. 

Meagan: Okay.

This is actually higher than was previously thought. Our first-ever study that directly measured protein needs in pregnancy was done in 2015 and they found that our recommendations are way too low. 

Meagan: Yeah, 80-100 to me seems really low. I’m not pregnant and typically try to get more protein than that. 

Lily: Well, 80-100 is a lot more than what the current recommendations are. 

Meagan: Which is crazy, yeah. 

Lily: The current recommendations for late pregnancy on average are about 71 grams of protein per day. 

Meagan: Whoa. 

Lily: Yeah. 

Meagan: Wow. So we need to beef it up. We need to get some protein in. 

Lily: Yep. It depends on the person too. We have some individuals who are highly physically active or maybe if your blood sugar is really, really sensitive to carbohydrates, you might do better having a higher proportion of protein in your diet than another person. So while 80-100 is a good minimum ballpark metric, you might do better aiming for 100 or 110 grams per day in early pregnancy and later on aiming for 120-150 grams. It really depends on the person. 

Meagan: It all depends, yeah. 

Lily: Yeah. 

Meagan: That is pretty crazy. 

19:11 Best Sources of Protein

Meagan: Okay, now we know we’ve got to get our protein. What are the best sources of protein? That is something that I do find that sometimes is hard. It’s really hard to get whole protein and sometimes I do have to supplement with a shake or add some protein collagen to my oatmeal or something. So what types of proteins or what sources of proteins or what ideas could we give to our listeners?

Lily: Yeah. When you think of protein, there are a lot of different foods that contain protein, but they have proteins in different concentrations or there’s a different balance of amino acids within those proteins. Our highest quality, the best balance of amino acids, and the highest concentration of protein per the amount of food you are eating is from our animal foods. So meat, fish, eggs, dairy, seafood– those have your highest concentrations of protein relative to any of the other macronutrients. 

As you go into your plant source proteins, you’ll have a lower proportion of protein and just a different or more incomplete amino acid balance. You’ll get a lot more carbohydrates along with that protein, but they, of course, have other positive things in them. Plant proteins come with fiber, for example. Our beans and legumes of plant proteins would be the highest quality ones that you can get. We have significantly smaller proportions of protein in our grains, for example. Nuts and seeds are a decent source. 

You can also get, of course, all sorts of protein supplements. They can extract protein from anything that is protein-rich and market it as a supplement. We have our grass-fed whey protein and our beef protein isolate and we have rice protein concentrate and all sorts of things. You have your pick. If you are not getting enough from food, you can always supplement with additional on the side, but my recommendation really is to try to get a balance of different protein sources since there are pros and cons of all of our different proteins. Just try to get a mix. That amount and forms might be different from person to person based on their preferences. 

22:04 Getting Enough Protein on a Meatless Diet

Meagan: Yeah. That makes total sense. Kind of talking about how some things have less, for any listeners that maybe are not eating meat or don’t eat meat, how? I mean, just eating a lot of legumes and beans and nuts and stuff like that? Or how? I don’t know. Is there a higher risk there if we don’t eat meat? Does that make sense? Is it harder to get it in and how can they focus more on getting that? 

Lily: It is. It is a bigger challenge. Vegeterians and vegans do consume on average significantly less protein than omnivores. You can kind of plan around it by having a higher proportion of beans and legumes versus grains and considering some specific high protein options like tempe, and fermented soy products. I’m not a huge fan of a lot of soy, but fermented soy as long as it is organic can be okay and tempe is quite high in protein and relatively low in carbohydrates. Your nuts and seeds can contribute more and you can consider supplemental protein options. 

It does definitely get tricky particularly as we talk about gestational diabetes with blood sugar management on a vegetarian and vegan diet simply because most of our plant sources of protein if you are consuming them as a whole food, they have a significant amount of carbohydrates. So sure, you can get protein from beans, but beans also have carbohydrates. 

Meagan: I’m sure. 

Lily: There’s some protein in quinoa, but it’s 8 grams of protein per 40-something grams of carbohydrates in that serving whereas if you were going to consume 8 grams of protein from meat, that’s literally a little more than 1 ounce of meat and it has 0 carbohydrates. When you are looking at macronutrient balance, it gets a little bit trickier. 

So for vegetarians and vegans– I mean, with vegetarians, you have eggs and dairy so you can do more eggs. You can do more low-carbohydrate dairy products like cheeses, cottage cheese, greek yogurt, dairy protein powders, and egg protein powders and that makes the macronutrient balance much easier. 

With vegans, we generally do need to rely on some supplemental protein powders just so we are not overdoing the carbohydrates. It does get significantly trickier. It’s not that it’s not doable, but there are of course, always different trade-offs with different dietary approaches. 

Meagan: For sure. 

26:17 Fats & Gestational Diabetes

Meagan: So we’ve talked a little bit about the carbs and the proteins and the fats. A lot of, say salmon or even eggs. We’ve got egg whites but then we’ve got yolks which consume a lot of fat. How does fat play into or does it play into gestational diabetes?

Lily: Similar to protein, fat does not raise your blood sugar levels so generally speaking, fat is not something you need to be overly worried about necessarily. That definitely flies in the face of conventional guidelines that tell you to limit your fat production significantly. We have to be really cautious when we talk about limiting fat in pregnancy. 

First of all, we are in a situation where your hormone production is higher than ever. Our sex hormones like estrogen and progesterone are built on a backbone of cholesterol which you get in fatty foods, specifically your fatty animal foods. Whatever you don’t consume, your body produces. So if we are cutting out all of the fat out of everything, you actually run into problems with hormone production. 

They have shown this in studies where they limit fat in women. Estrogen and progesterone production can be 20-50% lower. Even though your body has the ability to create cholesterol from other precursors, it still negatively impacts hormone production to not be consuming it. I do get concerned about that. 

I do also get concerned that when you start limiting fat from food, you’re also limiting your intake of a lot of micronutrients. Egg yolks– you gave the example of egg yolks. Egg yolks are high in cholesterol, yes. They are also the richest dietary source of choline which is a nutrient we need for optimal placental function and optimal fetal brain development, and when we are not getting enough, it’s linked to many significant problems. I mean, we now have very high-quality studies like randomized controlled trials showing that taking in actually more than double– the current recommended intake for choline improves child brain development through their toddler years all the way– the study has now been extended through age 7. They have followed these kids through age 7 and they have better brain function essentially at those later ages. 

If you are cutting out egg yolks for the goal of reducing your fat or cholesterol intake, you are essentially setting yourself up for a choline deficiency. Half of the choline an average American takes in is from eggs. It is such a concentrated source. You can extend that to many other examples for many other nutrients in foods that naturally contain fat. It’s a significant concern of mine actually. People get so laser-focused on fat that they lose the big picture on what are you missing out on. 

Meagan: What it’s actually giving you. 

Lily: Yes, exactly. I’m not a big fan of limiting the fat intake. Particularly, when you are talking about blood sugar control, if you are reducing your carbohydrate levels, then you are reducing the calories taken in from carbs. You have to eat something else, right? We can only eat so much protein so it always ends up being a dance between– are you eating more carbohydrates or are you eating more fat? That’s always how the balance is made up in terms of our macronutrient ratios. 

Certainly, I love the protein. I’m all about eating protein, but our protein-rich foods do naturally come with fat, so what I am personally not a fan of is people obsessively taking out the fat of all of their protein-rich foods. Just eat the fat that is in there. You don’t need to add massive quantities of fat to everything you are eating, just don’t take out what is naturally there. 

Meagan: Yeah. Yeah. I love that you talk about that because one of the things– so I’m a doula and I’ve seen this in all the years of being a doula, but then I’ve also seen this trend of messages coming in like, “I’m scared to eat too much. I’m scared to eat fat. I’m scared to eat these things because I’m scared of a ‘big baby’” or “I’m scared of having to have a C-section because my baby is measuring big,” or they are so scared of shoulder dystocia so they are now having to induce me at 38 weeks which we already know with gestational diabetes, a lot of the times, providers encourage induction early anyway. 

Ladies, do not cut out your fats. Eat your good proteins. Get the right kind of carbs. 

31:14 Do we have to have a baby at 38 weeks with Gestational Diabetes?

Meagan: What does it look like with gestational diabetes? Do we have to have a baby at 38 weeks like many providers suggest? Do we always have a big baby if we have gestational diabetes? 

Lily: Absolutely not. 

Meagan: Right? 

Lily: Absolutely not. 

Meagan: Can we talk about that and cross out those myths? 

Lily: Yep. We have very strong data actually that when we are able to keep blood sugar within range as much as possible– it’s not going to be perfect, but as much as possible, keeping your blood sugar within a healthy level and your provider should give you some healthy guidelines. If you don’t, go read “Real Food for Gestational Diabetes”. 

Meagan: Seriously. Go get your book and the link is in the show notes, everybody. 

Lily: Yeah. We see a 50% lower risk of macrosomia. That’s the baby being born larger than expected. 

Meagan: Too large, yeah. 

Lily: We see a 60% lower risk of shoulder dystocia. 

Meagan: Wow. 

32:28 The Problem with the Standard Gestational Diabetes Guidelines

Lily: These risks absolutely can be lessened with dietary and lifestyle intervention. What frustrates me the most and it’s why I wrote “Real Food for Gestational Diabetes” in the first place, is that the standard guidelines for dietary management of gestational diabetes fail to improve outcomes because they often fail to control blood sugar levels because they are arbitrarily way too high in carbohydrates. 

So what ends up happening is you get these women who get a meal plan that says, “Eat 45-60 grams of carbohydrates at a meal, a super minimal amount of protein, barely any fat” because this is all just an off-shoot of the standard dietary guidelines, and their blood sugar goes way too high after their meals. They are like, “What is going on? I’m eating per the guideline.” 

Meagan: I’m following. 

Lily: Yeah, exactly. Unfortunately, they are simply consuming way too many carbohydrates for what their body can tolerate. I mean, it makes no sense. If you failed a glucose tolerance test meaning your blood sugar was not able to come down within range when you had anywhere from 50, 75-100 grams of glucose in one sitting? Why are we then giving you 45, 60, 75 grams of carbohydrates which turn into glucose in a sitting at a meal, and saying that this is treatment? It is not treatment and anybody with a toddler-level logic can see that it makes no sense whatsoever. 

Meagan: No sense. 

Lily: Ironically, it’s very controversial advice to recommend a lower than that carbohydrate intake and that’s precisely what I present in my book with the evidence to back it up, but that still remains the standard of care. So then what ends up happening, you get these women who end up afraid to eat because they are worried about their blood sugar going too high. 

Meagan: Exactly, yes. 

Lily: So they eat the same type of meal but a really, really, really tiny portion and they are starving. 

Meagan: Yes. And they are malnourished. 

Lily: Exactly. They are malnourished. 

Meagan: They are not getting the macro or micronutrients in their bodies. 

Lily: It is tragic and it is unethical in my opinion, so if you do find yourself in that scenario where you feel like you are having to starve yourself to keep your blood sugar within range, after you check your blood sugar after that meal, you are clamoring for a snack because you are so hungry, there is another way. 

Meagan: Yes. 

Lily: It does involve nourishing yourself enough. You have to get enough calories in. 

Meagan: Yes. 

Lily: You can get enough calories and micronutrients in without the blood sugar spike just with a different macronutrient balance. You need to be eating a lot more protein. You need to ditch the fear of fat. You need to eat a quantity of carbohydrates that your body can manage in one sitting. Oftentimes, that isn’t 45-60 grams or 75 grams of carbohydrates per meal. That might be 10 or 15 or 20 or 30 grams of carbs in a meal. 

Meagan: Right. 

Lily: It might mean eating your protein-rich foods first before you have your carbs at the end of the meal. That can significantly change how your blood sugar responds. 

Meagan: Okay. 

Lily: But the standard approach is very ineffective and I can tell you when they have actually done studies where they switch people to a lower glycemic index diet, so better quality carbohydrates, more protein, and the chances that a woman will require insulin to manage her blood sugar drops by 50%. 

Meagan: Whoa. 

Lily: That can make the difference between your birth being sabotaged, overly intervened, you being denied a VBAC, them trying to scare you into the “your baby is too big” and that whole conversation. That can make a difference of it. So we really need to get better information out because it’s not fair. Gestational diabetes is poorly managed and it’s overly medicalized when it is diagnosed. 

Meagan: I feel the same. I feel it is. Some people have described it as, “Oh, it checked off a box saying you are in this category automatically because you tested positive.” Then they do. They go down rabbit holes. Women of Strength, if you are listening and you are someone who feels that they can’t eat a lot or you are in that space and you are the person that we are describing, you are not alone. You are not alone in this world. 

But, you have more options. That is why I wanted to do this episode because it makes me want to cry because I hate and I feel their frustration. It also makes me want to punch someone, not our listener, but it makes me just want to punch somebody and be like, wake up. give different information and stop putting this pressure of, “You can’t have a VBAC. you’re going to have shoulder dystocia. You have to have a baby by 38 or 39 weeks.” All of these things or “Your baby is too big.” It’s just, why? Instead of just diving in learning how to better manage and to eat better. Eat more real foods. 

Lily: I mean, if your blood sugar is maintained in a healthy range for the majority of your pregnancy, you are not at any higher risk than anybody who didn’t get a diagnosis. All of these things are potential risk factors, I mean, in the macrosomia conversation, you can have women who passed a gestational diabetes test, but maybe they gained quite a bit more weight than is expected over the course of their pregnancy. They are actually oftentimes at a higher risk for macrosomia than the woman who was diagnosed with gestational diabetes and had excellent blood sugar control. Nobody talks about that, right? 

To me, the difference is really in how you manage it. I think we have to try to lose the fear over the diagnosis. It is an unfortunate reality that for a lot of providers, you can be treated differently because of the diagnosis even though I disagree with that, but you can maintain actually quite a low-risk pregnancy, sometimes an even lower risk than if you hadn’t been diagnosed because if you see this as a blessing in disguise and take it upon yourself to improve your diet and lifestyle and really buckle down on this and get your blood sugar in a healthy range, you now are having a healthier pregnancy than if you didn’t have the diagnosis because you are taking a moment to be like, “Hmm, yes I’m pregnant and I’d like to eat for two, but you know what? I’m actually full. I don’t think I’m going to have that extra cupcake.” 

It’s all of those consistent blood sugar elevations without a gestational diabetes diagnosis that is contributing to the baby growing larger than expected. When you bring the blood sugar within range, we see a significantly reduced risk of macrosomia. 

Meagan: Yeah. This episode, I feel like, has so many really great tips on just how to eat better in general during pregnancy even if you don’t have gestational diabetes. 

Lily: Yes. Absolutely. 

40:20 PCOS and Gestational Diabetes

Meagan: Before we were recording, we were talking about your new book. You said something that caught my ear and I was like, “Wait, what?” because PCOS which is polycystic ovarian syndrome– is that correct? 

Lily: Mhmm, correct. 

Meagan: It runs in my family. You were talking about how PCOS could be a sign. 

Lily: It’s a risk factor for gestational diabetes, yeah. Absolutely. 

Meagan: Yeah, so can we talk a little bit more about some of those risk factors and how if we maybe have these things we may need to be extra aware and intentional? 

Lily: Intentional, yep. That’s a good word for it. With that, PCOS is a bit of a complicated diagnosis. There are different subtypes. There are actually four phenotypes and they are all just a little bit different. They share some overlap, but they are all a little bit different. That said, the majority of PCOS cases do have some degree of insulin resistance going on in their body. Your body doesn’t respond normally to insulin and brings your blood sugar down within range with a normal level of insulin. Your body has to release a lot of insulin to bring your blood sugar within range. 

Meagan: Wow. 

Lily: This is a risk factor for gestational diabetes because, during pregnancy, your body naturally becomes a little more insulin resistant. So if you are already coming into pregnancy with that baseline challenge with your body responding to insulin, when your body starts pumping out more insulin, your insulin resistance is going up and up and up, it can just compound and be too much for your body to handle. Your blood sugar will surpass that threshold of so-called gestational diabetes. 

That is a significant risk factor. It also tends to be– PCOS is the most common ovulatory issue in women, so it can make conception a little more challenging. It can make timing sex accurately for conception more challenging because oftentimes, there are really long cycles or delays in ovulation so it’s harder to time it right although women with PCOS can conceive successfully naturally. It can just be a little more tricky. 

And then when there already is a blood sugar issue going on ahead of time, there is a higher rate of early miscarriage as well. Now, things that you do for managing PCOS, there is a lot of overlap with the same concepts for managing gestational diabetes. If you do have that diagnosis and you are thinking about becoming pregnant, you can implement some of the same tips that we talked about today or blood sugar management. Higher protein, fewer carbohydrates, better quality carbohydrates, eating your protein-rich foods first at mealtimes, and considering supplementing with certain nutrients to reduce your level of insulin resistance. 

There is some really excellent data on inositol which is a B vitamin compound for reducing insulin resistance and improving ovulation and ovulatory function in these women and that is a supplement that honestly, they’ve done studies where they have put it head to head with metformin which is the most common medication prescribed for women with PCOS. It is also prescribed for gestational diabetes management and it often performs the same or better than metformin so inositol is a really viable option that women can look into and consider supplementing with. 

We talk about it pretty extensively in Real Food for Fertility as an option along with many other nutrients. There are a lot of other micronutrients that play a role in keeping our level of insulin resistance down as much as possible. So just improving overall the quality of your diet where naturally, you are just displacing more and more of these processed foods from your life because these also are so rich in micronutrients, you’re naturally improving the function of your pancreas and how responsive your body is to insulin and your blood sugar doesn’t spike as much because you aren’t getting as much refined carbohydrates in. 

There’s a lot of these things that all work in tandem and they work together. They continue to be important during pregnancy as well, so wherever you are, start now. Start thinking about this now. 

Meagan: Start now. Yes. Start now. It’s never too late to start. Like I was saying in the beginning, we live a busy life so that quick granola protein bar that is easily unpackaged in the car that you can take a bite of might be an okay snack but might not be the best. Maybe carrots. Maybe you can have carrots. 

Lily: Or maybe having a bag of nuts or some beef jerky. The nuts would be similar to a granola bar, but they are much lower in carbohydrates. They have more protein, fat, and fiber in them so they won’t spike your blood sugar, but they may fill you up better than a granola bar and with a significantly lower blood sugar spike for sure. 

Meagan: And I guess carrots are a lot of carbs so it turns into sugar. 

Lily: I mean, carrots do have carbohydrates, but they have quite a bit of fiber in them, so they are a fine option as well. They are just pretty low in protein and have no fat and they are so low in calories that solely as a snack–

Meagan: It’s not going to help you feel full. 

Lily: Yeah. It’s not going to keep you full. I’ve got nothing against carrots. Carrots are excellent, but maybe having them with a cottage cheese dip or something like that would at least provide you with a little more sustenance. 

Meagan: Yes. Going back to the protein. See? We forget about the protein. 

Lily: Yep. 

Meagan: Focusing on the protein. Wow, I just adore you. I think this is such a great episode. I need to just go get your books now. I mean, I’m not even pregnant. I’m done with having babies, but I want to dive in more. I want to learn more because like I said, it’s such a hot topic for our VBAC community especially because we have so many naysayers like, “Oh, you can’t do this if you have this.” 

So okay, tell us more. You’ve got your website, lilynicholdsrdn.com and I know you’ve got the blog, your shop, your books, and all of the things. Tell us more about where we can find you and what resources we can use. We’re going to make sure to put everything in the show notes, you guys. 

Lily: Yeah, so up on my website, definitely click the Freebies tab. You can download a free chapter of Real Food for Pregnancy if you want to dive more into what is real food. What are you talking about? That is available for free. There is a free video series on gestational diabetes that is really helpful to help you if you have just been diagnosed or are worried about being diagnosed. That will narrow down the starting point. The biggest thing I hear is that people are really afraid and overwhelmed by what to do. It just feels very dire. You are given the diagnosis. You are told that it comes with these risks and you are not told any good news, so I try to be the bearer of good news and empowering information so you can actually take action on that. 

Meagan: I love that. 

Lily: Probably those two resources would be of most interest to this audience. I’m also on Instagram. My handle is @lilynicholsrdn so pretty much the same as my website. And yeah, keep an eye out for the new book, Real Food for Fertility in February 2024. 

Meagan: It’s coming out this month. This episode is being aired in 2024. That is so exciting. That one is on infertility, correct? On fertility. 

Lily: Yeah. It’s on fertility. That one I actually coauthored this book with my colleague Lisa Hendrickson Jack. She is the host of The Fertility Friday Podcast and author of The Fifth Vital Sign. We joined forces to talk about the food and nutrition part, the fertility hormone/menstrual cycle part and it really is the best of both worlds from our respective specialties. 

Meagan: I love that so much. Well, we will have the links for both of your books and then like she said, give her a follow so you can know when this new book is coming out. 

Closing

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